What is the appropriate dosing of ketorolac (Toradol) for acute pain management in the Emergency Department (ER)?

From the Guidelines

Ketorolac (Toradol) in the emergency department for acute pain should be dosed at 15-30 mg IV, every 6 hours as needed, with a daily maximum of 120 mg for a maximum of 5 days, as this dosing regimen is supported by the most recent and highest quality evidence 1. The medication works by inhibiting cyclooxygenase enzymes (COX-1 and COX-2), reducing prostaglandin synthesis and providing potent analgesic and anti-inflammatory effects comparable to opioids for acute pain. Some key points to consider when prescribing ketorolac include:

• Avoiding use in patients with active peptic ulcer disease, recent GI bleeding, advanced renal impairment (creatinine clearance <30 mL/min), those at high risk for bleeding, or in the setting of suspected or confirmed cerebrovascular bleeding.
• Limiting the duration of therapy to a maximum of 5 days, due to the increased risk of adverse effects with prolonged use.
• Using the oral dose not exceeding 40mg/day following parenteral administration, to minimize the risk of gastrointestinal and renal toxicity.
• Considering alternative analgesics, such as opioid analgesics, in patients who are at high risk for renal, GI, cardiac toxicities, thrombocytopenia, or bleeding disorder, as supported by the evidence 1. It is also important to note that ketorolac should not be administered concurrently with other NSAIDs due to increased risk of adverse effects, as stated in the evidence 1.

From the FDA Drug Label

KETOROLAC TROMETHAMINE INJECTION Ketorolac tromethamine injection may be used as a single or multiple dose on a regular or “prn” schedule for the management of moderately severe, acute pain that requires analgesia at the opioid level, usually in a postoperative setting. Single-Dose Treatment: The following regimen should be limited to single administration use only Intramuscular Dosing Patients <65 years of age: One dose of 60 mg Patients ≥65 years of age, renally impaired and/or less than 50 kg (110 lbs) of body weight: One dose of 30 mg. Intravenous Dosing Patients <65 years of age: One dose of 30 mg. Patients ≥65 years of age, renally impaired and/or less than 50 kg (110 lbs) of body weight: One dose of 15 mg Multiple-Dose Treatment (Intravenous or Intramuscular) Patients <65 years of age: The recommended dose is 30 mg ketorolac tromethamine injection every 6 hours. The maximum daily dose for these populations should not exceed 120 mg For patients ≥65 years of age, renally impaired patients (see WARNINGS), and patients less than 50 kg (110 lbs): The recommended dose is 15 mg ketorolac tromethamine injection every 6 hours. The maximum daily dose for these populations should not exceed 60 mg.

The appropriate dosing of ketorolac in the ER for acute pain is as follows:

• Single-dose treatment:
  • Intramuscular: 60 mg for patients <65 years, 30 mg for patients ≥65 years or renally impaired and/or <50 kg
  • Intravenous: 30 mg for patients <65 years, 15 mg for patients ≥65 years or renally impaired and/or <50 kg
• Multiple-dose treatment:
  • Patients <65 years: 30 mg every 6 hours, not to exceed 120 mg/day
  • Patients ≥65 years or renally impaired and/or <50 kg: 15 mg every 6 hours, not to exceed 60 mg/day 2

From the Research

Appropriate Dosing of Ketorolac in the ER for Acute Pain

• The appropriate dosing of ketorolac in the ER for acute pain is a topic of interest, with studies suggesting that lower doses may be as effective as higher doses in certain patient populations 3.
• A study published in 2023 found that parenteral ketorolac doses of 15 mg IV or 30 mg IM did not demonstrate a greater need for rescue analgesia compared to doses of 30 mg IV or 60 mg IM in patients 65 years and older 3.
• Another study published in 2023 found that ketorolac was the most effective in reducing pain score at 30 and 60 minutes in patients with acute renal colic, with a lower adverse event profile compared to morphine 4.
• The use of ketorolac in patients with renal dysfunction is not well-studied, but a review of the pharmacokinetics and side effects of opioids in patients with impaired renal function suggests that ketorolac may be a safer alternative to opioids in this patient population 5.
• A retrospective study published in 2020 found that administration of ketorolac was associated with a modest decrease in IV opioid use in patients with non-specific abdominal pain, with an adjusted odds ratio of 0.84 for receiving IV opioids and 0.79 for receiving multiple doses of IV opioids 6.

Considerations for Dosing

• The dosing of ketorolac should be individualized based on the patient's medical history, current medications, and renal function.
• Patients with renal dysfunction may require lower doses or more frequent monitoring due to the potential for increased risk of adverse events.
• The use of ketorolac in combination with other analgesics, such as acetaminophen, may be effective in reducing pain and opioid consumption in certain patient populations 7.